Education and Counseling

Behavioral Changes and Lifestyle Modifications

Health promotion and disease prevention rely heavily on individuals making lifestyle modifications. No matter how advanced medical technology becomes or how well evidence based recommendations are crafted – behavior change is critical. When we talk of behavior change, we usually are referring to three general categories:

  1. Reduction or elimination of destructive behaviors (e.g., smoking)
  2. Promotion of healthier lifestyles (e.g., healthier food choices)
  3. Adherence to medical regimens (e.g., taking medications as directed)

Individual behavior change can be achieved through modifications to the built environment, reform of the educational system, mass media messaging, and changes in economic and social service policy. For a physician working one-on-one with patients, behavior change is often achieved through counseling. Counseling interventions can range from brief advice to more intensive interventions, with research demonstrating a significant impact on health promotion and disease prevention. For smoking cessation counseling in primary care, it has been estimated that increasing rates of brief physician advice (1-3 minutes) would yield an additional 63,000 quitters per year, while coupling this with intensive 10-minute counseling by staff would increase this ten-fold (Whitlock et al, 2002). This is supported by studies, for example, showing an almost 15% absolute increase in biochemically validated quit rates at 6-month follow-up for diabetic patients at primary care clinics provided with nurse-managed assistance (Ranney et al, 2006).

Behavioral Change Models

Doctors report discomfort with their counseling skills and misjudge their own effectiveness. Physicians feel more confident administering medication or doing a procedure. Some overestimate the effectiveness of their counseling skills, while others are frustrated by a perception of limited progress.

The behavioral change skills explored and developed during the introduction to clinical medicine coursework in medical school are pivotal when counseling patients in the clinical setting. A brief review of the “stages of change” model will help in applying behavioral change skills in everyday health care.


Returning to our case: Y.S. is 24-year-old white female medical student who presents to you at the student health clinic today for her first visit. She has no complaints but just wants “a check-up.” She is in good health. She used to suffer from acne as a teenager but her skin has cleared up since she turned 18. She takes no medications currently and has no known drug allergies. She has no history of surgeries. Y.S. denies any mental health history, denies any issues with depression or eating disorders, and tells you she is doing well academically in medical school. She has been sexually active only with her boyfriend for three years. They use condoms exclusively. They have a “good relationship” and she denies any arguments or abuse. Y.S. has not smoked or used recreational drugs in the past or currently. She drinks one or two “Cosmos” on Saturday nights with her friends. She does not drive, but her boyfriend has a car.

You bring up the topic of contraception with her. Y.S. says she does not want children at this stage of her life, and does not believe she is at risk for sexually transmitted diseases from her monogamous relationship. She prefers to use only condoms as contraception at this time, because she “doesn’t want to gain weight on the pill.” She is, however, concerned about the possibility of the condom breaking. She is not sure what she wants to do about the issue yet.
Which one of the following stages of change is this patient at?

  1. Pre-contemplation
  2. Contemplation
  3. Preparation / Determination
  4. Action
  5. Maintenance
  6. Relapse

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Motivational Interviewing

Physicians can help patients reflect at each of the stages of change. Physicians can also support patients in moving from ambivalence towards lifestyle change and maintenance of healthy behaviors. Counseling techniques based on Models of Motivational Interviewing (Miller and Rollnick, 1991) are more effective than criticism, exhortation, lecturing, or threats of terrible consequences. According to the psychological theory of reactance, individuals resist coercion by others and try to maintain a sense of autonomy. Patients who were initially open to discussing their worries, become defensive about their behavior if they perceive coercion. Motivational interviewing supports patient behavior change by building on their own motivation. Successful interviewing integrates empathy, curiosity, and reflective listening; focuses on self-determination and acceptance; and explores ambivalence (e.g., gratification from continuing an unhealthy behavior and positive health outcomes expected from changing that behavior).

Motivational interviewing can be used during the six stages of change:

  • With patients in the pre-contemplative stage, a physician can request permission to discuss the issue, express concern, or ask the patient to think or read about the issue between visits.
  • During the contemplation phase, the clinician can ask about the patient’s opinions on the issue, or help the patient weigh the pros and cons.
  • During the preparation / determination stage, the provider can summarize the patient’s reasons for the behavior change, negotiate a start date to begin the behavior change, and encourage that the patient make a “public” announcement about the change.
  • During the action stage, the physician provides support, modifies the plan if not optimal, and schedules follow up contact to provide further support.
  • During the maintenance stage, the clinician continues to give support and admiration for the behavior change, asks about commitment to change in the future, and ask about the patient’s expectations.
  • If a patient does relapse, the provider can reassure the patient that relapses occur on the pathway to long term change, and relapses can offer opportunities to learn in preparing for the next action stage.

The following brief video has an example of motivational interviewing as applied to weight loss counseling.

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